PURPOSE: This rule establishes the guidelines for determination of recipient liability for medical services not reimbursable to the provider by the Medicaid agency.

1. (1) When an enrolled Medicaid provider provides an item or service to a Medicaid recipient eligible for the item or service on the date provided, there shall be a presumption that the provider accepts the recipient’s Medicaid benefits and seeks reimbursement from the Medicaid agency in accordance with all of the applicable Medicaid rules. This presumption shall be overcome only by written evidence of an agreement between the provider and the recipient indicating that Medicaid is not the intended payor for the specific item or service but rather that the recipient accepts the status and liabilities of a private pay patient. All third-party resource benefits must be exhausted before payment will be made by the division for the item or service rendered to that recipient. For purposes of this rule, neither the provider nor the recipient shall be required to exhaust all third-party resources in those situations where the provider or recipient elect not to pursue contingent liability from a third-party tortfeasor. Both the provider and the recipient have an affirmative duty to report the existence of contingent liability to the Division of Medical Services and the recipient has the duty to cooperate with the Division of Medical Services if the division elects to pursue the contingent liability.
2. (2) When an item or service is rendered to a Medicaid recipient who was eligible for the item or service on the date provided and provision of the item or service is billed to the Medicaid agency by an enrolled Medicaid provider who is not reimbursed by the agency for the item or service claimed, the item or service will not be the liability of the recipient if the item or service would have been otherwise payable by the Medicaid agency at the Medicaid allowable amount had the provider followed all of the policies, procedures and rules applicable to the item or service as of the date provided. If the item or service is not otherwise payable for reasons unrelated to the actions of the provider, the recipient is liable to the provider for payment of the item or service.
3. (3) The creation of a presumptive acceptance by a provider of the Medicaid benefits for a Medicaid covered service and the requirement for written evidence of an agreement to overcome presumptive acceptance, as established in this rule, shall not be applicable to services provided to a recipient who is dually eligible and entitled to both Medicaid and Medicare Part B medical insurance benefits.
4. (4) The provisions of this rule shall apply to items or services provided on or after July 11, 1985.

AUTHORITY: sections 207.020, 208.152 and 208.153, RSMo 1986.* This rule was previously filed as 13 CSR 40-81.140. Original rule filed April 16, 1985, effective July 11, 1985. Amended: Filed March 2, 1988, effective May 12, 1988. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986; 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978(2), 1981, 1986, 1988, 1990; and 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991.